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SAN JOAQIJII. 'OUNTY ENVIRONMENTAL HEALTH I, PAWFMENT <br /> SERVICE REQUEST <br /> Type of Business or Property j <br /> /FACILITY IID/# ./ SERVICgE REQIU/ESOT# <br /> SAFEWAY FUELING FACILITY <br /> OWNER/OPERATOR <br /> SAFEWAY INC. CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SAFEWAY STORE #2707 <br /> SITE ADDRESS 6425 PACIFIC AVENUE STOCKTON 95207 <br /> Street Number Direction I Street Neme city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number st,NA Name <br /> CITY STATE ZIP <br /> PHONE#1 E„r. APN# LAND USE APPLICATION# <br /> ( l <br /> PHONE#2 Ezr. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR _ <br /> - --...... ..------------- <br /> REQUESTOR <br /> SUZANNE RUSIT CHECK if BILLING ADDRESS <br /> BUSINESS NAMEPHONE# EMT. <br /> RHL DESIGN GROUP INC. 925 313-9700 <br /> HOME or MAILING ADDRESS FAX# <br /> 1340 ARNOLD DR., STE 110 (925 ) 313-9709 <br /> CITY MARTINEZ STATE CA ZIP 94553 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent ol'same, <br /> acknON%lcdac that all site and/or project specific ENVIR1ONMI.N IAI HEACill DLPARJ'0FN'r hourly charges associated with this project <br /> or acticit.� +H ill he billed to the or my business as identified on this form. <br /> I also"ink Ihal I hacc prepared this applieation and that the work t he perlormed will he done in accoidanct:with all SAS JOAQ1. I', <br /> CoIrNtY U1liruln1.c Cods,.S'lundurrla,Sime an;( F'Et laws. <br /> AI=PLICANT'S SIGNA'I'URI1: I).ATE: 09/11/03 <br /> PIL(IrKN"I'1'/BvsSess ONN nr:N❑ rtaa:rrol /P Act:N ❑ OTna:NAt.ruoni/I:n,+c:a:�Ni ® JOB CAPTAIN <br /> 7 is o!rhe. L3illlc l Tl,proojnfnut/lorization to sign is required Title <br /> AUTHOItIL,A'1'ION '1'O H-LEASEORNI:F'I'ION: When applir.161z, h the owner or operator of tl1e protmrty located at the <br /> abo%e site address, herebv author/C IIIc rcicd c 01 any and all results, geotechnical data and/or emironmental/Site assessment <br /> irll'onnal'.ion 10111C S.AN JOAQUIN(a d N 1 Y L:N\'lltl INMI'N'I AI. 111'AI I I I DLPAIt I MI N IaS S0011 as it is BvailllhlC agdttrlt the SaInC lillte it is <br /> pim idrd to me or my representati+e. <br /> TYPE OF SERVICE REQUESTED: TANK INSTALLATION EG ' <br /> COMMENTS: <br /> SEP OPO \N 5 N NS\ON <br /> SIa e�GHEPljNFP\ZH�\ <br /> pU Nts\FNtP\ <br /> rNNt�c <br /> APPROVED BY: EMPLOYEE#: DATE: G <br /> ASSIGNED TO: EMPLOYEE DATE: Z ` 3 <br /> Date Service Completed (if already completed): SEF —13 1 P I E: 2'J <br /> Fee Amount: (o S O Amount Paid O( O Payment Date <br /> Payment Type t/ N Invoice# Check# O l , J1) ff 4 L/ Received By:to <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 65-02 <br />